Building a Transgender-Affirming Practice

Narrator: Welcome to Clinicians Roundtable on ReachMD. The following activity, titled “Building a Transgender Affirming Practice” was recorded at Prova Education’s Guidelines to Practice.

Our host is Dr. Matt Rosenberg, and joining him is Ms. Zil Garner Goldstein, Family Nurse Practitioner, Assistant Professor of Medical Education at the Icahn School of Medicine, and Program Director at the Center for Transgender Medicine and Surgery at Mount Sinai.

Here’s Dr. Rosenberg.

Dr. Rosenberg:
Transgender medicine encompasses many gender identities of those who do not identify, or exclusively identify, with their sex assigned at birth. The term transgender is not indicative of gender expression, sexual orientation, hormonal makeup, physical anatomy, or how one is perceived in daily life. The medical knowledge needed to treat transgender patients is not necessarily complex; however, patients often struggle to find doctors who are adequately trained to prepare to treat them.
Our expert today will discuss ways to build a transgender-affirming practice. So, first of all, thank you very much for joining us.

Ms. Goldstein:
It’s my pleasure.

Dr. Rosenberg:
And let’s first review why it’s so important to engage transgender patients in healthcare.

Ms. Goldstein:
There’s a very high incidence of HIV in transgender women. That’s probably the most important reason. The second reason is that transgender people rely on the medical system in order to live their most fulfilled lives. Transitioning requires going to a medical provider, getting hormones, getting surgery, and being able to engage in care. Now, the flip side of that is that oftentimes people have difficulty engaging in care, but we really want to be able to help people affirm their identities. Like we said, there’s a 40% suicide attempt rate in the transgender community. And in order to save those people’s lives, we need to be offering transition-related care to help them live fulfilled lives and improve their mental health outcomes.

Dr. Rosenberg:
What are some of the challenges that transgender patients might face in accessing medical care?

Ms. Goldstein:
Medical care isn’t really built to help transgender people. What’s the first thing that you do when you get to an office? You go to the front desk and you give them your ID. What if your ID has the wrong name on it? What if it doesn’t match the name that you like to be called? What if they don’t ask for ID and you tell them your name and that doesn’t match the name that is on your medical records? So, there’re so many opportunities for transgender people to have a poor experience when they’re seeking medical care. Any staff member can offend a patient, just trying to do their jobs as best they can. We’ve had janitors who have tried to keep people from going into the bathroom that aligns with their gender identity. Again, they’re just trying to do their job, and they haven’t had the adequate training to work with transgender people. And so, we end up in these conflicts with our patients that get in the way of providing good patient care.

Dr. Rosenberg:
For me personally, I am the lead physician for a large group, and this is something we’ve actually been actively having discussions on recently. We teach here at a few of the medical schools and have residents with us, and this has come up in the last year or two, just with the whole world changing in a lot of ways, in not some good ways and some bad ways, but challenging ways. From your perspective, what challenges do healthcare practices face when trying to engage in transgender patients?

Ms. Goldstein:
It’s really easy to unintentionally hurt a transgender person’s feelings and drive them away from healthcare. Having the expertise to take care of transgender patients from a medical perspective, as well as the expertise to create a welcoming environment from a cultural competency perspective, both take extra work, because medicine doesn’t prepare us to take care of transgender people. Specifically, having record systems that will give us a place to document preferred name and preferred pronouns; having staff that are aware of how we need to be working with transgender patients; taking the time out of our busy days to teach our staff, and to learn ourselves, how to work with transgender patients. These are all things that take a little bit of extra work. And it’s really easy for us to blame the patients and say that it’s their fault that we are taking so much time, or it’s so difficult to work with the patients because they have such special needs. It’s important to contextualize that and to know that the medical system is built to be inherently transphobic and inherently not meet the needs of transgender patients.

Dr. Rosenberg:
So, for example, in our practice, as we see patients of many, many backgrounds with many, many issues, one of the ways that I’ve been able to deal with this is I will, when I meet a patient for the first time, I’m like, “Look, let me know how to identify with you and please let me know if we’ve ever done anything that you’ve found malignant. We may not have done it intentionally, in fact, we probably didn’t, so you have to let us know, because if it happened to you, it may be happening to somebody else.” What kind of advice would you give practices along that line?

Ms. Goldstein:
Well, I think it’s great to offer patients a chance to give feedback at every opportunity you can do so. It’s exactly right, if one person has a bad experience, that’s probably being replicated for many other patients who may not be speaking up. So, on a patient-to-provider level, that lets them know that you care about what their experience is, and on a practice improvement level, that lets you fix the problems. We have patient satisfaction surveys, of course we’re using Praschini, but we also have additional surveys that go out to all of our transgender patients, asking how their office visit was, did someone use the wrong name, did someone use the wrong pronouns? What can we do to make it a more welcoming environment for them to get their care?

Dr. Rosenberg:
This is an evolution and we’ll be having a next-step conversation in a year, and hopefully we’ll be better for it. So, you’re telling me as, again, a lead in a family practice, which a lot of our audience is, give me the top three things you would like us to do as a medical practice, to make our offices more welcome.

Ms. Goldstein:
Well, the first thing is just a shameless plug, but hire transgender staff.

Dr. Rosenberg:
Okay.

Ms. Goldstein:
That is the absolute best thing that you can do to make your office a friendly place for transgender people. Not only will they see someone who looks like them working there, but your transgender staff will be able to point out potential problems that patients will face when trying to access care at your office. The second thing, find a place to document preferred name and preferred pronouns, and make sure everyone on site knows where that is. And the third thing is to have some sort of sign, some sort of poster, or pamphlet, or something where if someone walks in and they can see that this is a place that is at least putting their best foot forward and trying to accommodate transgender patients.

Dr. Rosenberg:
Fantastic. Okay. So, I’m going to go to the next level on that question. That was the medical practice, now, three things I can do as the healthcare provider, in my case a physician, but it will be also for a nurse practitioner, or a PA, what can I specifically do so that we’re more welcoming?

Ms. Goldstein:
Learn how to prescribe hormones in a way that makes you comfortable doing so. People often have to educate their providers on what it is that they need, which is the opposite. Just imagine, going to our own doctors and saying, and we were to have a sinus infection, and the doctor says, “I don’t know what a sinus infection is.” How many of you would then trust that person to treat your sinus infection. Knowing that that person is probably not requesting hormone care for the first time when they come in. Knowing that even if you refer out, that’s going to feel like a rejection for the transgender patient.

Dr. Rosenberg:
This is relatively new. Not new, but relatively new for each provider, and what if we said, “You know what? I want to help you. I’m going to be your advocate. Can I work with you and an endocrinologist to figure out what works best for you?”

Ms. Goldstein:
Well, then you have to make sure you have an endocrinologist.

Dr. Rosenberg:
That would be our job. We can do that.

Ms. Goldstein:
Right. Well there’s many endocrinologists out there who don’t know how to take care of transgender patients.

Dr. Rosenberg:
So, we have to find the right one?

Ms. Goldstein:
Right.

Dr. Rosenberg:
But that’s we can do. I mean, I think any provider can work as a patient advocate or, knowing what we know, and knowing what we can do in helping find the people who can help us help the patient.

Ms. Goldstein:
Exactly.

Dr. Rosenberg:
Okay. So, before we conclude, I think we have just about a minute left, but are there any additional comments or takeaways that you’d like to share with us?

Ms. Goldstein:
My message triangle is: there’s an extreme need for people to create places for transgender people to get care from both medical and cultural competency perspectives. Do something. Prescribe hormones, even if you’re not 100% sure. Just remember back to when you first started practicing and you weren’t 100% sure of any decision you made. So, access, access, and the third part of a message triangle is also access. It’s incredibly important. I’m just going to say it one more time: 40% of transgender people attempt to commit suicide and this is lifesaving work.

Dr. Rosenberg:
Thank you very much.

Narrator:
This has been an episode of Clinician’s Roundtable on ReachMD, provided in partnership with Omnia Education.
Thank you for listening.